A H Mohd Mustamam N Muhammad Farid Wong Y J Lee N Mohd Ali



Massive pulmonary embolism is defined as acute pulmonary embolism with sustained hypotension, pulselessnes or bradycardia. The combination of history taking, clinical findings, prediction probability test and bedside echocardiography is of value in diagnosing and treating unstable pulmonary embolism patient.


A 48 year old Chinese male with underlying lung carcinoma ongoing currently on chemotherapy, presented to Emergency Department with sudden onset shortness of breath started the morning of arrival. Patient had has been having cough with minimal sputum, denies with no fever, no hemoptysis, no chest pain and no heart failure symptoms. On examination patient was hemodynamically unstable with moderate respiratory distress, other systemic physical examination is was unremarkable. Bedside echocardiography showed right ventricle hypertrophied and dilated with paradoxical septal movement, low end diastolic left ventricle volume and plethoric inferior vena cava. Well’s criteria calculated with a score of 3 which is was high possibility of pulmonary embolism. In view that the patient was unstable for CT-PA and with combination of history given and other clinical findings suggested patient was having massive pulmonary embolism. The patient was thrombolysed with IV Tenecteplase 50mg and subsequently admitted to ICU. Patient showed overall marked improvement. CT-PA done later showed right pulmonary artery embolism.


The above case was a classic presentation of massive pulmonary embolism which is marked with persistent hypotension. CT-PA is the gold standard for diagnosing pulmonary embolism but in unstable massive pulmonary embolism it is not possible to be done. In the latest guidelines by European Heart Journal and American College of Physician recommended the use of prediction probability test to proceed with the treatment. In cases of uncertainty and with many differential diagnosis, it is important to combine history taking, clinical findings and other modalities such as prediction probability test and bedside echocardiography to determine diagnosis and management.


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